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ANNUAL FEE and REPORT REOUEST <br />PERMITTEE NAME: Rio Blanco County RE C IF R /ED <br />PERMIT NO.: M-2004-038 JAN 15 2009 <br />OPERATION NAME: West Johnson Draw Division of Reclamation, <br />Mining and Safety <br />ANNIVERSARY DATE: January 7, 2009 <br />ANNUAL FEE DUE: $323.00 (Due on or before your anniversary date) <br />COUNTY: Rio Blanco <br />According to C.R.S. 34-32.5-116 or_C.R.S. 34-32-116, each year, on the anniversary-date- of the permit, an_ _ _ <br />operator shall submit the annual fee, a report and -map showing the extent of current disturbances to -affected <br />land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to <br />occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach your revised written annual report and annual report map to this form. The Annual <br />Report & Fee requirement is not met until we have received the following components: fee, report, and <br />associated may. If no new disturbances or reclamation have occurred durinz the previous year and no <br />new changes to the previous year's map are necessary. then no new map is required. provided that the <br />Operator shall state this in the Annual Report. Please note that an adequately labeled map that clearly <br />delineates and includes the above elements may suffice for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: <br />Ron,eeper <br />-0ewi'c( Mo; L V, <br />Permittee Name <br />Address: <br />Phone Number: <br />Rio Blanco County <br />570 2nd St. <br />Meeker, CO 81641 <br />(970) 878-9590 <br />Fax Number: (970) 878-3396 <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />below or attach it to this form along with your written report and map. Annual Report instructions are <br />enclosed. <br />AM 0 10 10"_' - <br />igna re of Corpor e Officer, Owner, or Designee <br />/.2 A'0.4 <br />Date <br />M:\PERMIT\MASTERDOCUMENTS\A4-AF-04